NCC213910_NOI Application_20210702

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/30/2021 2:12:17 PM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 7/1/2021 10:44:33 AM (Review- Construction NOI 58052)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 6/30/2021 2:12 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: July 2, 2021 5:00 PM.
The priority is: High 6/30/2021 2:12 PM
Submit by Selkane, Aziza 7/2/2021 8:38:09 AM (Payment Verification for NCC213910)
* Charles H West Jr
• Selkane, Aziza assigned the task to Selkane, Aziza 7/2/2021 8:37 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: August 12, 2021 5:00 PM.
The priority is: High 7/1/2021 10:44 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting r No
an NOI that was r Yes
rejected before?
Previous Rejected 58009
NOI No.
Prior Reviewer Brooklyn Broussard
Name
1a. Project Name* Food Warehouse Project
1 b. Specific Lot This field may be used to list specffc lot numbers.
Numbers
1 c. Parcel ID List all R% associated w ith this project.
Number(s) (PIN) Portion of 0017.00.00.0023.0000
2. County* Caswell
3. Highway or Street NC 700
Address* Street name only is acceptable if no address number assigned yet
4. CityorTownship* Pelham
5. State * NC
6. Zip Code* 27311
7. Latitude* Enter the latitude in decimal degrees
36.5258
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-79.4801
If you do not know the latitude and longitude coordinates for this project, you can search the location on this map of
North Carolina. Look for the coordinates in the bottom left corner.
9. Date to Begin* 03/12/2021
Estimated Construction Project Start Date
10. Date to End* 12/31/2021
Estimated Construction Project End Date

11. SIC (Primary)* Commercial (1542)
Standard Industrial Classification for Development
12. Acres to be 3.07
disturbed* (including off -site borrow and waste areas)
13. Total site area 8.50
(acres) *
14. Post- 1.00
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-CASWE-2021-Food Warehouse Project
Tracking ID Assigned automatically
Below you must enter waterbody information for surface waters affected by this project. Please consult
DWR's Surface Water Classifications Map Viewer to find waterbody name and corresponding index number. Please
enter only immediate receiving waterbodies - not waters downstream of those unless the project extends there. You
may enter up to 3 waterbodies if needed.
15a. Receiving Dan River/Roanoke River Basin
Waterbody* Name of waterbody into which stormwater runoff will discharge
15b. Waterbody 22-(39)
Index No. * NCWaterbody Index Nurrber
Stormwater V No
discharges will flow r Yes
to additional
wate rs *
16a. Is this project r Yes
subject to the NC r No, not subject to NC SPCA
Sediment Pollution
Control Act?*

B. Permittee Information
Part B. ^
F2rnittee Inforrration - Legally Fbsponsible Entity and Individual
Important: The person who signs the NOI Certification Form and signs the Certification in Section E of this application
form should be the same person as listed in THIS SECTION, or an authorized responsible individual within the same
organization. That person must be a responsible corporate officer who owns or operates the construction activity, such
as a president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV,
Section B, Item (6) of the NCG010000 General Permit. For more information on signatory requirements, see Part
IV, Section B, Item (6) of that permit.
1. Organization Legally Pesponsible Entity
Name * West Leasing, L.L.C.
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
Note: The organization name must match the business entity name registered with the NC Secretary of State. You can
verify the registration here.
2. First Name * Charles
If Corporation, enter Faegistered Agent First %rre
3. Last Name* West
It Corporation, enter Pbegistered Agent Last %rre
3b. Title Member
4. Permitee E-mail [e-mail]
Address*
5. Permittee 828-837-2437
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box 129
Address Line 2
City
Murphy
Fbstal / Zip Code
28906
Check box if the F Yes
street address the
same as mailing
address
State / Frovince / Fbgion
NC
Country
USA
7. Permittee Street
Street Address
Address*
1268 Andrews Rd
Address Line 2
city
State / Frovince / Faegion
Murphy
NC
Fbstal / Zip Code
Country
28906
USA
8. Type of
Ownership is only individual if an individual
is naned in B.1. above.
Ownership*
Non -Government

C. Site Contact Information
Part C.
Project Site Contact Inforrration
_..................................................................................................................................................................
1. Primary Site
Charles
Contact - First
Name *
2. Primary Site
Burger
Contact - Last
Name *
3. Title
Superintendent
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
434-724-7920
Telephone No.
6. Organization
Crews Construction
Name
7. Site Contact
Street Address
Mailing Address*
14001 Mt Cross Rd
Address Line 2
city
Dry Fork
Postal / Zip Code
24549-3125
8. Consultant Name
(Optional)
First and Last narre
9. Consultant E-mail
This person will be copied on all correspondence.
10. Consultant
Telephone No.
11. Billing E-mail
(For Annual Fee correspondence)
[e-mail]
Default is legally responsible person e-rreil
12. Billing
(For Annual Fee correspondence)
Telephone
828-837-2437
Default is legally responsible person telephone
State / Province / Region
VA
Country
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 03/12/2021
Approved *
2. E&SC Plan Project CASWE-2021-005
Number/ID * Assigned by agency or local program
3. E&SC Plan r State DEQ Office
Approved by* r Local Program
4. State DEQ Office * Winston-Salem (WSRO)
Documentation of E&SC Plan approval and the signed Notice of Intent (NOI) Certification Form is required for a
complete application. Please also upload a site map showing the overall extent of the project (for linear projects, can
include the beginning point and end point coordinates in the "Notes" box below).
5. E&SC Plan Certificate of Approval E&SC Plan Pelham.pdf 66.12KB
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Mist be RDFforrret (lint 201VB)
Pelham NOI Map.pdf 898.6KB
Rease do not upload entire set of E&SC plans.
7. Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded docurrents support
the application. Include additional waterbodies if necessary.
the Letter of approval states the address as NC 700, we have
changed this, The Acres Approved are on the Letter of Approval
are 3.07 which we transferred to the NOI, The supplied coordinates
are taken from the internet. The Project name listed on the letter of
Approval is Food Warehouse Project which we transferred to the
NOI.
8. NOI Certification NCG01 upload.pdf 42.79KB
Form Mist be RDFformat
This is an Express r No
Review Project* F Yes

E. Certification
North Carolina General Statute 143-215.66 (1) provides that:
Any person who knowingly makes anyfalse statement, representation, or certification in any application, record, report, plan, or other
document filed or required to be maintained under this Article or a rule implementing this Article; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Artcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the
Commission implementing this Artcle shall be guilty ofa Class 2 misdemeanor which may include a fine not to exceed ten thousand
dollars ($10,000).
Under penalty of law, I certify that:
17 I am the person responsible for the construction activities of this project, for
satisfying the requirements of this permit, and for any civil or criminal penalties
incurred due to violations of this permit.
rJ The information submitted in this NOI is, to the best of my knowledge and belief,
true, accurate, and complete based on my inquiry of the person or persons who
manage the system, or those persons directly responsible for gathering the
information.
* 17 I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* rJ I hereby request coverage under the NCG010000 General Permit and
understand that coverage under this permit will constitute the permit
requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
Specify if you are:* r The Legally Responsible Person named on this Notice of Intent
r Authorized Responsible Person* (signing on behalf of Legally Responsible
Person named in Part B)
Important: The person who electronically signs this Certification above must be the same person who signs the NOI
Certification Form. If that person is signing on behalf of the Permittee, that individual must be an authorized responsible
person within the same organization as the Permittee. *An authorized individual is a responsible corporate officer who
owns or operates the construction activity, such as a president, secretary, treasurer, or vice president, or a manager
that is authorized in accordance with Part IV, Section B, Item (6) of the NCG010000 General Permit. For more
information on signatory requirements, see Part IV, Section B, Item (6) of that permit.
Signature
+1if1-r e e/"'/Iru�
Type Name * Charles H West
Title Member
Organization Legally Responsible Entity
West Leasing, L.L.C.
Date * 06/30/2021

F. Tracking and COC Info
NOI Tracking No. 58052
NC Reference No.
NCG01-2021-3910
Uses 'count_nurber' variable (increrrented by SP)
Certificate of
NCC213910
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 3910
Sequential nurrber for subrrittal that is incremented by Stored Frocedure
COC Year 2021
Year of date reviewed (used to assign YY digits after "NOC' in COCno.)
Initial Invoice No. NCC213910-2021
Invoice Due Date 7/31/2021
Initial Fee $ 100.00
Invoice Status OPEN